Our experience suggests that even with standard definitions, information on ambulance report forms may be abstracted inconsistently.

The purpose of this study was to determine whether shorter prehospital scene time (ST) is associated with an increased survival rate in non-traumatic, out-of-hospital, cardiac arrest (CA) in a medium-sized, metropolitan EMS system. Information was retrieved for all adult victims (age ≥18 years) of CA treated and transported by a metropolitan fire department over a 16month period (6/87–9/88). Data were retrieved from the fire department's database, hospital records, and death certificates. Statistical analysis of continuous variables was performed using the two-tailed, Student's t-test and non-parametric evaluations were performed by square analysis with p<0.05 considered significant. Two hundred ninety-eight cases were recorded of which 293 patients (98.3%) had documented ST (study group). Seventy-nine patients (27.0%) had ST <12 minutes, while 214 (73.0%) had ST≥12 minutes. Patients with ST <12 minutes were more likely to have return of spontaneous circulation in the field (26.6% vs. 15.9%, p<0.05) and also were more likely to survive than were patients with ST ≥12 minutes (13.9% vs. 6.5%, p<0.05). Mean ST for survivors was significantly less than for non-survivors (12.8 vs. 15.3 min., p<0.05).

We conclude that, in our system, adult victims of CA with ST <12 minutes are more likely to survive than are patients with longer ST. In addition, the mean ST for survivors is shorter than for non-survivors. It remains unclear whether shorter ST actually has an impact on survival or is merely a reflection of a sub-group with rapid resuscitation and consequently a higher likelihood of survival. Future investigations are needed to determine whether shorter ST actually impacts the likelihood of survival from CA.

Local advanced life support (ALS) medical directors in North Carolina choose the skills and medications they want utilized in their jurisdiction from a list of options authorized by the State Board of Medical Examiners. We surveyed all 35 medical directors of paramedic providers in the state to determine which optional skills and medications local medical directors allow to be used and, therefore, how they tailor their prehospital practices. Information concerning the urban or rural status of the paramedic service area, annual call volume, and the specialty classification of the medical director also were obtained.

All of the medical directors surveyed responded. Twenty-one (60%) of the paramedic service areas were rural and 14 (40%) urban. Twenty-three physicians (66%) listed emergency medicine as their primary specialty. Annual call volumes ranged from 580 to 33,500. Skills allowed by >80% of the medical directors include: drawing blood, insertion of esophageal and endotracheal airways, defibrillation, cardioversion, and initiation of intravenous fluids prior to hospital contact. The majority permit the administration of bretylium, dopamine, NaCl injection, sodium bicarbonate, furosemide, sublingual nitroglycerin, diazepam, diphenhydramine, and morphine. The majority do not allow the use of positive-pressure ventilators and do not allow administration of dobutamine, nifedipine, procainamide, propranolol, local procaine, isoetharine, metaproterenol, nitroglycerin paste, 10% dextrose solution, methylprednisolone, mannitol, phenytoin, meperidine, or nitrous oxide. Nitroglycerin paste and dexamethasone were significantly (p<.05) more likely to be allowed in rural than in urban areas. No differences in utilization by medical director specialty classification or call volume were detected. The results suggest that, when given a choice, local ALS medical directors select a limited prehospital practice. Further study is warranted to determine why available skill and medication options are not utilized.

The National Disaster Medical System (NDMS) was formulated to provide medical care for casualties of future large-scale natural disasters and military conflicts. We sent questionnaires to the 59 emergency medical directors of North Carolina's participating hospitals in order to assess their views regarding the need for NDMS and the level of their hospital's preparedness. Responses were received from 78% (46) of the physicians surveyed. Of those responding, an overwhelming majority supported the need for a national plan like NDMS to treat casualties of a natural disaster or an overseas military conflict. Respondents also agreed that the participation of emergency department personnel, other physicians, and support personnel is essential for successful activation of NDMS. Responses to questions regarding level of preparedness, however, suggested that there is less than an optimal degree of preparedness for participation in NDMS.

This report from a member of the United Nations (UN) team of experts describes the investigations of the use of chemical weapons during the Iran-Iraq War. The UN-sponsored team of experts discovered evidence that clearly showed the use of three chemical weapon substances during that conflict—Yperite (Mustard Gas), Tabun (nerve gas), and Phosgene (respiratory irritant). The effects of these chemical agents and some means of treatment for victims are described.

Optimal, initial medical care given at the disaster site to victims of civil disasters requires an organized, pre-planned, disaster-site medical support system. Such a system has been developed in Singapore.

On notification of a serious civil disaster, the Coordinating Health Agency (CHA) initially dispatches up to three medical teams. Each team consists of two doctors, four nurses, and an allotment of pre-packaged medical supplies. A Disaster-site Medical Command (DSMC) head-quarters (HQ) is established, consisting of a Medical Commander (MC), a Deputy Medical Commander (Dy MC), three hospital staff, and a clerk. The MC conducts an initial assessment of the disaster site and then deploys medical teams and establishes the headquarters. The MC also informs the CHA (via cellular telephone) of the situation at the disaster site and when deemed necessary requests further medical assistance.

The MC has two-way radio contact with all medical teams. The medical teams relay information regarding the casualty situation, requirements for ambulances, stretchers, and medical supplies. Direct channel communication with the CHA enables the MC to direct ambulance transport of patients from the disaster site. The MC also has operational control over other paramedical teams from the Fire Service, the Singapore Red Cross, and the Singapore Armed Forces. Prior to transportation to the hospital, the medical teams only carry out trauma resuscitative procedures such as maintenance of airway, ventilation, and circulation.

This system is expected to provide a coordinated and rapid medical response to a civil disaster situation.

Prehospital and hospital emergency medical care providers frequently rely on the electrocardiogram (ECG) to assist them in the differential diagnosis of complex patient problems and as such, the ECG often constitutes a major determinant of the definitive treatment selected. The purpose of this exercise is to review a small portion of the vast area of ECG interpretation: specifically, those rules that guide the practitioner in the diagnosis of Premature Ventricular Complexes (PVCs).

Premature ventricular complexes (PVCs) occur in multiple individuals in multiple settings. Due to these differences, the causes, implications, and treatment of PVCs must be individualized. Thus, the scope possible for this discussion is huge. Consequently, this exercise will focus only on helping the practitioner correctly identify PVCs.

Superpower military competition has abated, but the specter of nuclear weapons still adds a completely new dimension to warfare. The destructive capacity of so-called conventional bombs was made cruelly evident in the Second World War. Yet, today, a single, thermonuclear bomb has the explosive power of a million times the largest conventional device, with not only devastatingly immediate consequences but also extremely harmful long-term effects, both at the site of the attack and far away, in time and space (Figure 1).

In Figure 2, the small central circle with a radius of 1.4mm represents the combined area which would have been affected by the total of all the explosives used in the Second World War. The larger circle, with a radius of 100mm, represents the relative destructive power of the nuclear arsenals stockpiled today. This is a terrible and, hopefully, a sobering image.